Westland, A Villa Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 03/18/25 at 2:20 PM, room [ROOM NUMBER] was observed. The flooring was soiled with stains, and was sticky and dull in appearance. The bathroom flooring was also soiled with a buildup of grime. The over-bed table in the room was observed with the plastic edging pulling away from the surface, leaving rough, exposed particle board underneath. The surface was no longer smooth and easily cleanable. On 03/18/25 at 2:25 PM, the flooring in room [ROOM NUMBER] was observed with a black, gummy substance surrounding 7-8 floor tiles. On 03/18/25 at 2:30 PM, the flooring in room [ROOM NUMBER] was observed with a black, gummy substance surrounding several floor tiles. When queried about the black substance, Regional Housekeeping Supervisor stated, It looks like built up glue. Resident (R92), who resided in room [ROOM NUMBER] was queried about the room. R92 complained of old urine on the floor in the corner of her room, and stated it was from a previous resident. R92 also complained of urine odors in the bathroom. R92…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to complete in-service education performance reviews for five Certified Nurse Aides (CNA's Z, AA, BB, CC, and DD) of five reviewed for an annual performance review. Findings include: On 3/20/25 at 11:54 AM, a request was made for the required 12 hours annual resident care in-service education performance reviews for CNA's Z, AA, BB, CC, and DD. On 3/20/25 at 1:56 PM, the Director of Nursing (DON) reported they were contacting the third party education company for the staff education records. At 2:42 PM, the DON reported she did not have an estimate time that the company will be able to provide the education in-services. The request for the CNA's 12 hours of education was not provided by the end of the survey. A review of the facility's policy titled, Training Requirements Guideline dated 5/29/2020, revealed, Purpose: To inform and guide center leadership about training requirements and their role in the training development, implementation, and maintenance of an effective training program for all new and existing staff. 1 .…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain the exterior dumpster area in a clean manner. This deficient practice had the potential to affect all residents, staff and visitors. Findings include: On 3/8/25 at 9:30 AM, during an observation of the 2 exterior dumpsters with Dietary Manager (DM) O, there were several bags of trash observed on the ground in front of the dumpsters, a bag of trash on the side of the dumpster and a bag of trash behind the dumpsters. There was an accumulation of loose trash items in between the 2 dumpsters and along the sides of the dumpsters. DM O stated Maintenance is responsible for cleaning up the dumpster area. Review of the undated policy Food-Related Garbage and Rubbish Disposal noted: Outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter.

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices, storage of nebulizer mask for two residents (R32, R655), clean blood pressure cuffs, and elements of the infection control program were completed potentially affecting all 194 residents that reside in the facility. Findings include: On 03/20/25 at 10:10 AM, a review of the infection control program was conducted with the Director of Nursing (DON) who was acting as the interim Infection Preventionist. The DON noted that during a recent outbreak of the flu multiple residents were treated prophylactically. Education related to the outbreak was requested but not provided prior to survey exit. A review of the monthly summaries revealed: In January 2024, 21 facility acquired infections were documented and based on a census of 200 the infection control rate was: -In February 2024 the rate was 14.5%; -In March 2024 the rate was 11%; -In April 2024 the rate was 11%; -In May 2024 the rate was 7%; -In June 2024 the rate was 10.5%; -In July 2024 the rate was 12.5%; No staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Mental Illness/Intellectual Disability Related Condition Level 1 Screening and failed to complete a Level II evaluation for four residents (R44, R177, R4 and R10) out of five reviewed for PASARR's. Findings include: R44 A review of the medical record revealed that R44 admitted into the facility on 2/17/2025 with the following diagnoses, Post-Traumatic Stress Disorder (PTSD) and Bipolar Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 11/15 indicating an impaired cognition. R44 also required staff assistance with bed mobility and transfers. Further review of a PASARR screening on file dated 7/24/2024, revealed that Yes was checked for the following questions, 1. The person has a current diagnosis of Mental Illness or Dementia 2. The person has received treatment for Mental Illness or Dementia 3. The person has routinely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to serve food in a palatable manner and at the preferred temperature for four residents ( R30, R53, R69, R154) of six residents reviewed for food palatability. Findings include: R69 On 3/18/25 at 7:07 PM, R69 reported the food is horrible. R69 explained, the residents does not have any input on the food, the facility picks and choose what they are going to serve. The residents are not offered a menu before hand. A review of R69's medical record noted, R69 was admitted to the facility on [DATE] with diagnosis Chronic Pulmonary Disease. A review of R69 quarterly Minimum Data Set (MDS) assessment dated [DATE] noted R69 with an intact cognition and required assistance with activities of dialysis living. R154 On 3/18/25 at 10:10 AM, R154 reported the food is always cold. On 3/19/25 at 3:58 PM, they have asked me my likes and they still send what they want which are my dislikes. On 3/20/25 at 9:15 AM, R154 was asked about their dinner and stated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure care conferences were conducted regularly for one resident (R133) of one resident reviewed for care conferences. Findings include: On 3/18/25 at 9:34 AM, R133 was asked about their care in the facility, and they explained they have a difficult time with getting their needs met due to their concerns falling on deaf ears. A review of R133's medical record revealed they were admitted into the facility on [DATE] with diagnoses which included, Morbid Obesity, Stiffness of right hand, Stiffness of left hand, Muscle Weakness, Muscle Wasting and Atrophy, and Schizophrenia (mental health disorder). Further review revealed the resident was cognitively intact and was dependent on staff for bed mobility and transfers. A review of R133's medical record revealed they were supposed to have had care conferences on the following dates: 2/20/2024, 8/6/2024, and 11/19/2024. On 3/20/25 at 9:16 AM, Social Worker T was asked about missed care conferences, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain dignity during tube feeding, for one resident (#43) of three residents reviewed for tube feeding. Findings include: On 3/17/25 at 7:19 PM, R43 was observed in their room in bed. On 3/18/25 at 10:09 AM, R43 was observed in a geri chair sitting in the hallway. R43's tube feeding was started, the formula bottle and machine were both exposed to anyone that walked passed. R43's shirt was up exposing their stomach, tubing, and patch. On 3/20/25 at 3:39 PM, R43 was observed in a geri chair sitting in the hallway. R43's tube feeding was started, the formula bottle and machine were both exposed to anyone that walked passed. R43's shirt was up exposing their stomach, tubing, and patch. A review of R43's medical record noted, R43 was admitted to the facility on [DATE] with diagnosis of Down Syndrome. A review of R43's annual Minimum Data Set (MDS) assessment dated [DATE] noted, R43 with a severely impaired cognition and dependent of staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one resident (R70) and provide a proper fitting wheelchair for one resident (R131) out of two residents reviewed for accomodation of needs. Findings Include: R70 On 3/17/25 at 6:45 PM, R70 was observed sitting on their bed. The call light was observed hanging out of reach above the resident's bed. R70 was asked how they're supposed to use their call light if it's out of reach, and they stated, How do you use it? A review of R70's medical record revealed they were admitted into the facility on 2/23/23 with diagnoses that included Alzheimer's Disease, Diabetes and Muscle Weakness. Further review of the resident's medical record revealed the resident was independent to extensve assistance for activities of daily living. On 3/17/25 at 8:06 PM, the resident's call light remained hanging above their bed and out of reach of the resident who was observed sitting on their bed. On 3/18/25 at 8:57 AM, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure updated and accurate advanced directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for one resident (R2) of two residents reviewed for advanced directives. Findings include: A review of R2's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Dementia, Muscle Weakness and Schizophrenia. Further review revealed the resident had a moderate impaired cognition, and was independent for bed mobility and transfers. Further review of R2's medical record revealed the resident's code status indicated Full Code (a preference to receive all possible life-saving measures in the event of a cardiac or respiratory event). Further review revealed a document titled Do-Not Resuscitate Order (DNR) signed and dated by the resident on 10/12/23, signed and dated by a witness on 10/31/23, and sign and dated by the resident's physician on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to report and investigate a verbal altercation for two residents (R199 and R197) of six residents reviewed from abuse. Findings include: On 03/17/25 at 6:43 PM, R197 was the only resident in the room at the time with two other beds. R197 was asked if they had roommates in one of the beds and they stated, (name of R199) was removed from the room. R197 explained on early Sunday (3/16/25) morning, R199 called the nurse out of her name and cursed at them (two roommates) and threatened the two of them. A review of R199's electronic medical record did not reveal a note regarding the room change or of the verbal incident. On 3/20/25 at 1:50 PM, the Social Worker was asked the reason R199 was moved to another room. The Social Worker explained they moved R199 because of a verbal altercation with the roommate. The Social Worker was asked for the facility's investigation and reported that there was no formal investigation documented regarding the incident. Further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR) Mental Illness/Intellectual Disability Related Condition Level 1 Screening and failed to complete a Level II evaluation for one resident (R3) out of five reviewed for PASARR's. Findings include: A review of the medical record revealed that R3 admitted into the facility on [DATE] with the following diagnoses, Bipolar Disorder and Weakness. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R3 also required staff assistance with bed mobility and transfer. A review of the physician orders revealed that R3 was on Seroquel (Antipsychotic), as well as Ativan (Antianxiety), Zoloft (Antidepressant) and Buspirone (Antidepressant). Further review of a PASARR screening on file dated 12/6/2024, revealed that No was checked for the following questions, 1. The person has a current diagnosis of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement care plan interventions for two residents (R13 and R196) of three residents reviewed for care planning. Findings include: R13 On 3/17/25 at 7:47 PM, R13 was observed sitting in their wheelchair at the entrance of their bedroom. Attempts to interview the resident were difficult due to their speech however, the resident did indicate they needed a new remote for their television. On 3/18/25 at 12:45 PM, R13 was observed awake in bed, floor mats folded up next the bed. Also located in the room was an unidentified staff member who appeared to be sleeping. She was asked who she was and indicated that she was providing 1:1 supervision for the resident because they are known to throw themselves on the floor, and at times refuses dialysis, so she attends with him. A review of R13's medical record revealed the resident was admitted into the facility on [DATE] with diagnoses that included Metabolic Encephalopathy, Muscle…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure two (R4 and R44) of three residents had timely revisions for care plans. Findings include: R4 On 3/20/2025 R4 was observed sitting in a wheelchair in their room while lunch trays were being passed. When R4 did not receive a tray, an inquiry was made regarding R4's meal. Unit Manager (UM) J revealed R4 was now NPO (nothing by mouth). Further inquiry revealed R4 was having increased difficulty during lunch on 03/19/2025 with their pureed diet. The Electronic Medical Record (EMR) review revealed R4 was admitted on [DATE] with pertinent diagnoses of Cerebral Infarction (Stroke), Schizoaffective Disorder, Depression, seizures, and Oral Phase Dysphagia (Difficulty Swallowing). R4's Basic Interview for Mental Status reveals a score of 99/15 indicating R4 was rarely/never understood. R4 was dependent for all activities of daily living and mobility. On 03/20/2025, a review of the Electronic Medical Record (EMR) revealed a physician order for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00150867. Based on observation, interview, and record review, the facility failed to provide 1:1 feeding assistance, and ensure bathing was provided per the plan of care for two residents (R32 and R177) of nine residents reviewed for activities of daily living (ADLs). Findings include: R32 On 3/18/25 at 9:29 AM, R32 was observed sitting in their wheelchair. The resident was observed with hair on their upper lip and chin, long nails with an unknown brown substance underneath, and unkempt greasy hair. The resident was asked if they receive showers regularly, and explained that they did not, and could not remember the last time they had received a shower, had their nails trimmed or the hair on their face shaved. A review of R32's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Muscle Weakness, Heart Failure, Depression, and Paroxysmal Atrial Fibrillation. Further review revealed the resident was cognitively intact. On 3/19/25 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to schedule a follow up ophthalmology appointment in a timely manner for one resident (R146) out of one reviewed for vision. Findings include: On 3/17/2025 at 7:30 PM, an interview was conducted with R146. R146 reported they are waiting to be sent out to see an eye specialist. R146 reported they have not heard anything about when they would be going out, or what the hold up was. A review of the medical record revealed R146 admitted into the facility on 1/13/2025 with the following diagnoses, Critical Illness Myopathy and Muscle Weakness. A review of the most recent Minimum Data Set assessment 15/15 indicating an intact cognition. R146 also required staff assistance with bed mobility and transfers. Further review of the medical record revealed R146 had seen the in-house vision group at the facility, and they recommended that R146 go to an ophthalmologist due to retinol bleeding in both eyes. On 3/20/2025 at 9:51 AM, an interview was conducted with Unit Secretary Y. Unit Secretary Y' reported their supervisor brought the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an accident-free environment for one resident (R177) out of one reviewed for accidents. Findings include: On 3/20/2025 at 10:04 AM, R177 was observed in their room. R177 was noted to be laying in bed, and their breakfast tray was off to the side of them. The tray ticket had that R177 was to have paper products only and was highlighted in capital letters. R177's breakfast tray was noted to be glass, and they also had regular cups and silverware. On 3/20/2025 at 10:10 AM, Licensed Practical Nurse (LPN) W. LPN W was shown the regular plates for R177 and queried as if they should have them. LPN W indicated that R177 likes to throw and break plates, so they should have paper products for safety reasons. LPN W stated they were unsure about what happened. On 3/20/2025 at 11:05 AM, an interview was conducted with Dietary Manager (DM) O. DM O reported that R177 was not supposed to have regular plates, and they are supposed to have paper products as requested by the nursing staff. DM O reported they have a new…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to obtain physician orders for colostomy (an opening through the skin for the collection of bowel movement) care for one resident (R32) out of one reviewed for colostomy care. Findings include: On 3/18/25 at 9:29 AM, R32 was observed sitting in their room, and was asked about their care and explained they have a colostomy bag that hasn't been changed in 2 months. A review of R32's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Muscle Weakness, Heart Failure, Depression, and Paroxysmal Atrial Fibrillation. Further review revealed the resident was cognitively intact. Further review of R32's medical record revealed a Quarterly Minimum Data Set assessment dated for 1/10/2025 indicating that the resident has an Ostomy bag. Further review did not reveal a physician's order for the care of R32's colostomy. On 3/20/25 at 2:33 PM, the Director of Nursing (DON) was asked about the lack of orders for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure nurse staffing information was readily accessible for all 194 residents, families, and visitors in the facility. Findings include: On 3/17/25 at 7:20 PM, the staff posting for the day was observed to be incomplete without staff listed for the midnight shift. On 3/19/25 at 3:10 PM, the posting for today was observed incomplete without staff listed for the afternoon and midnight shift. On 3/19/25 at 3:21 PM, the scheduler was asked about the incomplete staff posting and reported she completes the form once she knows the staff for that shift. She further explained the reason for waiting to complete to form because if it changes it would be incorrect. On 3/19/25 at 4:11 PM, after a review of the 18 months of staff postings it was noted, the postings provided were not filling complete and the facility did not maintain access of 18 months of postings at the facility. The scheduler reported that the missing months were sent to be shredded at third party The scheduler explained, she may have not been at work on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the medication regimen irregularities were reviewed, acted upon, and documented in the medical record for one resident (R32) of six residents reviewed for unnecessary medications. Findings include: A review of R32's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Muscle Weakness, Heart Failure, Depression, and Paroxysmal Atrial Fibrillation. Further review revealed the resident was cognitively intact. A review of R32's monthly medication regimens revealed the following date in which irregularities were noted by the pharmacist during their monthly review: 11/24/24. On 3/20/25 at 10:51 AM, a request was sent to the facility requesting the irregularities report for 11/24/24 provided by the pharmacy, and the physician's response however, the report was not received by the end of survey. A review of the Physcian Services policy did not outline the process of reviewing pharmacy reports following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to complete an initial Abnormal Involuntary Movement Scale (AIMS) assessment for one resident (R44) out of one reviewed for unnecessary medication use. Findings include: A review of the medical record revealed that R44 admitted into the facility on 2/17/2025 with the following diagnoses, Post-Traumatic Stress Disorder (PTSD) and Bipolar Disorder. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 11/15 indicating an impaired cognition. R44 also required staff assistance with bed mobility and transfers. Further review of the physician orders revealed that R44 was prescribed and actively taking Seroquel (Antipsychotic). Further review of R44's medical record did not reveal an AIMS assessment which is used to detect abnormal movements across the face, lips, tongue, upper extremities, lower extremities, and trunk caused by antipsychotics. On 3/20/2025 at 1:41 PM, an interview was conducted with Social Worker (SW) T. SW T indicated the Psychiatric Nurse Practitioner was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to schedule recommended dental services for one of one resident (R133) reviewed for dental services. Findings include: 3/19/25 at 9:43 AM, R133 was observed lying in bed on their back. R133's teeth were observed as yellow and discolored, and was asked if they had seen a dentist since admission into the facility, and they replied, No. A review of R133's medical record revealed they were admitted into the facility on [DATE] with diagnoses which included, Morbid Obesity, Stiffness of right hand, stiffness of left hand, Muscle Weakness, Muscle Wasting and Atrophy, and Schizophrenia. Further review revealed the resident was cognitively intact and was dependent on staff for bed mobility and transfers. Further review of R133's medical record revealed the resident was seen for a dental exam on 5/29/24 and at that time, the following recommendations was made, X-rays were not taken because resident was seen in their room. Recommend resident be brought…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a functional call light for one resident (R61) of one resident reviewed for operational call lights. Findings include: On 3/17/25 at 8:55 PM, R61 was observed sitting in their wheelchair. The call light from the inside of the resident's room was lit up however, the light on the outside of the room which is used to bring awareness to staff that the resident needs assistane was not lit up. R61 was asked how long their call light had not been working and stated, It's been like this for awhile. On 3/18/25 at 9:12 AM, R61 was observed sitting in their room and further asked about their stay in the facility and explained that call lights are not answered timely. The call light remained unoperational from the outside of the door. On 3/20/25 at 10:51 AM, the work orders for R61's room were requested, and was informed there were no work orders for the resident's room. On 3/20/25 at 2:30 PM, the Director of Nursing (DON) was asked about the inoperatable call light for R61, and she indicated that she would follow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake: MI00149925 Based on observation, interview, and record review, the facility failed to implement a hand splint for one resident (R500) out of one resident reviewed for range of motion. Findings include: On 2/20/25 at 10:17 AM, R500 was observed lying in bed. R500's ring finger and little finger of their right hand appeared to be contracted inward. A hand splint was observed lying on top of a case of bottled water on the floor in the room. R500 was asked if they are supposed to wear the splint and R500 explained they think so, but no one has ever applied it or shown them how to wear it. A review of R500's record revealed, they were admitted to the facility on [DATE] with a diagnosis of polyarthritis. A review of R500's Minimum Data Set revealed the Brief Interview for Mental Status dated 1/23/25 was marked as not assessed indicating that R500's cognition was not assessed. A review of R500's record revealed no physicians order for a hand splint. A review of R500's care plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00149935. Based on observation, interview, and record review, the facility failed to properly store medications for one resident (R500) out of one resident reviewed for medication storage. Findings include: On 2/20/25 at 10:17 AM, R500 was observed in bed. Two bottles of Fluticasone nasal spray were observed on the night stand next to the bed within R500's reach. R500 explained they use the nasal spray themself. A clear plastic bag containing six medication bottles were observed in a wash basin on top of another night stand in R500's room. Three of the medications were Colace, Certizine, and Meloxicam. The writing on the other three bottles were worn off and illegible. A review of R500's record revealed they were admitted to the facility on [DATE] with a diagnosis of polyarthritis. A review of R500's Minimum Data Set revealed the Brief Interview for Mental Status dated 1/23/25 was marked as not assessed indicating R500's cognition was not assessed. A review of R500's physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00149448. Based on interview and record review, the facility failed to ensure laboratory (lab-blood sample) tests were completed timely for two resident (R901, R902) of three whose blood test results were reviewed, resulting in labs not completed and a delay in health assessment. Findings include: R901 A review of the facility record for R901 revealed, R901 was admitted into the facility 03/31/23. Diagnoses included Diabetes and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition and the need for partial assistance for most activities of daily living. A review of the physician orders with last review date of 12/30/24 documented a blood work lab order for Phenytoin (dilantin) trough (indicates lowest concentration), every night shift every three months with start date of 01/28/24. This order was documented as discontinued. A review of the lab result dated 07/02/24 documented a complete blood count (CBC) was completed, but under the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake #MI00147007. Based on observation, interview, and record review, the facility failed to prevent an accident for one Resident (R905) of three residents reviewed for accidents. Findings include: Review of a complaint received on 9/16/24 revealed, Per triage nurse [at the hospital] [R905] presented to the hospital 'after having a fall out of a [full body mechanical] lift onto [their] back and both legs'. [R905] is alert and oriented, no visible injuries .[R905] reports this is the 4th time this has happened with a [full body mechanical lift] [at the facility] . Review of R905's progress note, dated 9/16/24 at 00:59 p.m. (11:59 p.m.), by Licensed Practical Nurse (LPN) F, revealed, [R905] stated while in the [Full Body Lift name brand] [they] slipped down into the wheelchair. [R905] stated [they] hit [their] leg and back on the bar of the wheelchair. No injury noticed. [R905] was administered Buprenorphine [a pain medication] for pain. Writer [LPN F] reached out to PA [Physician's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00147006. Based on observation, interview and record review the facility failed to maintain a clean and homelike environment affecting eight rooms reviewed for environmental concerns. Findings include: On 09/24/24 at 2:36 PM, room [ROOM NUMBER] was observed to have a wall patch around three feet high by 18 inches wide between the end of the door bed and the side of the window bed. The patch surface was irregular and white dust was in a small pile below the patch. A approximate three inch high by one inch wide hole was observed centered on the door bed just above mattress level. On 09/24/24 at 2:59 PM, a pungent urine odor was noted in the hall in the area of rooms 409, 410 and 412. On 09/24/24 at 3:06 PM, in room [ROOM NUMBER] the drawers for both resident's closet cabinets were observed to hang down on the left side. On 09/25/24 at 10:35 AM, a resident reported a concern with the water dispenser in the vending area at the main entrance. Upon observation a quarter size area of a black…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00143993. Based on observation and interview, the facility failed to maintain a clean, homelike environment for one resident R701 out of one resident reviewed for environment. Findings include: On 06/06/24 at 10:00 AM, R701 was observed lying in bed in their room watching television. An observation of the privacy cubical curtains revealed several round brown stains on it. When asked about the curtains, R701 stated I have told them (housekeeping staff) about the curtains. Just looking at it is nasty and makes me sick. A record review revealed that R701 was admitted on [DATE] with the medical diagnoses of Major Depressive Disorder, Asthma, Respiratory Failure and Muscle Weakness. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 15 which indicates intact cognition. On 6/06/24 at 1:45 PM during an observation and interview with the Housekeeping Supervisor, (Staff A) they confirmed, The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

This citation pertains to Intake MI00143350. Based on interview, and record review, the facility failed to update a Preadmission Screening and Resident Review (PASARR screening) for one resident (R804) out of one reviewed for PASARR screenings. Findings include: A review of R804's PASARR Level I screening dated 9/27/2023 was completed and revealed that Section II, numbers 1 and 2 on the form were checked Yes with the diagnosis of Mental Illness checked and included a diagnosis of Anxiety and Schizophrenia. R804 was also taking antipsychotic medication at the time. The note section of the form noted the following, Note: The person screened shall be determined to require a comprehensive Level II OBRA evaluation if any of the above items are Yes, Unless a physician, nurse practitioner, or physician's assistant certifies on form DCH-3878 that the person meets at least one of the exemption criteria. Further review of the PASARR Level II screening dated 9/27/2023 revealed a hospital exempted discharge were checked and noted the following, Yes, I certify the patient under consideration: 1.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to change and date a peripherally inserted central catheter (PICC) line dressing for one resident (R802) out of one reviewed for PICC line dressings. Findings include: On 4/4/2024 at 8:47 AM, R802 was observed in bed and eating breakfast. R802 was noted to have an PICC line in their left arm. The dressing on the PICC line was lifting off and was not dated. R802 stated that their dressing had not been changed since the PICC line was put in at the hospital. R802 stated that they were currently not receiving any fluids or antibiotics. On 4/4/2024 at 8:51 AM, an interview was conducted with Licensed Practical Nurse (LPN) A. LPN A stated that they noticed that the PICC line was in and that they were going to call the nurse practitioner to obtain an order to remove it. A review of the medical record revealed that R802 admitted into the facility on 9/29/2023 with the following diagnoses, Metabolic Encephalopathy and Necrotizing Fasciitis. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 183 residents who receive meal services (12 nothing by mouth residents, or NPO) out of the facility's total census of 195 residents. Findings include: 1. On 2/7/24 at 9:46 AM, an accumulation of dust and debris was observed on the overhead fire suppression piping on the clean side of the dish machine. On 2/7/24 at 10:56 AM, an accumulation of dust and debris was observed on the overhead fire suppression piping above the steam table serving line. On 2/7/24 at 10:58 AM, upon interview with Regional Support Team Member, staff C, the surveyor inquired on who is responsible for the cleaning of the piping to which they replied, the high areas are taken care of by maintenance. On 2/7/24 at 9:46 AM, the dirty side of the dish machine's stainless steel loading countertop was observed leaking into a bucket on the floor. At this time Food Service Director, staff D, stated, a work…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

This citation pertains to intake MI00142158. Based on observation and interview the facility failed to provide a safe, functional, and sanitary environment for the facilities census of 195 residents and its staff resulting in an increased potential for harm. Findings include: On 2/7/24 at 9:34 AM, a restroom in the 100 hall was observed with a bag of liquid soap stored underneath the wall mounted soap dispenser on the edge of the designated hand washing sink, and a visibly wet stack of paper towels placed on top of the wall mounted electronic paper towel dispenser. On 2/7/24 at 9:50 AM, a visibly wet stack of paper towels was observed placed on top of the wall mounted electronic paper towel dispenser above the designated handwashing sink in the kitchen's dish machine room. Upon observation the surveyor inquired with Regional Support Team Member, staff C, on the why the paper towel dispenser is not being used as designed they stated, I think it to do with the keys to open it, but I'm not 100% sure. On 2/7/24 at 10:26 AM, a restroom in the facility's service corridor was observed with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to maintain the call light within reach for one (R141) of three residents reviewed for call light accessibility. Findings include: A review of medical record for R141 revealed an admission date of 10/02/23 with diagnoses that included Cerebral Infarction with Left Hemiplegia and Vascular Dementia. On 02/06/24 at 02:15 PM, R141 was observed in bed. When asked if the call light gets answered timely R141 stated I do not have the call light and rarely do. The call light was observed on the floor close to the head of the bed out of the resident's reach. On 02/08/24 at 12:08 PM, R141 was observed sitting in their wheelchair at bedside. R141's call light was observed out of reach on the floor blocked by two tray tables. On 02/08/24 at 01:24 PM, Certified Nurse Assistant (CNA) M was asked what they're understanding was about a resident's call light placement. CNAM gestured that call light should be attached to the resident's clothing. On 02/08/24 at 01:24 PM, R141's call light was observed on floor between the beds being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

This intake pertains to Intake MI00140161. Based on interview, and record review, the facility failed to ensure advance directives were in place for one resident (R68) out of two reviewed for advance directives. Findings Include: A review of Intake called into the State Agency noted the following, We also discussed (R68) mental status and whether (R68) is mentally competent at this point, as (R68) has vascular dementia. I was told by the social worker (SW) A .that they were placing a consult for a psychiatrist to come evaluate (R68) and determine if (R68) is competent or not. SW A explained that this was to be done by the end of that week. SW A also explained that [they] would call me and let me know the results, as I told SW A that I would need to file for guardianship if R68 is deemed incompetent. I have called a total of four times to try to reach the social worker, 3 out of those 4 times I left a voicemail. A review of the medical records revealed that R68 admitted into the facility on 7/5/2023 with the following medical diagnoses, Major Depressive Disorder and Dementia. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide nail care for one (R76) of 27 residents reviewed for activities of daily living (ADLs). Findings include: On 2/6/24 at 11:14 AM, R76 was observed lying in bed and was asked about the care at the facility and explained there were some things that needed to be fixed. During the interview R76's fingernails were observed to be long and with a build up of dirt under them. R76 was asked if they preferred their fingernails this way and stated, No. I don't but no one will do it. R76 explained that when the Podiatrist cuts their toenails they would also cut their fingernails. On 2/7/24 and on 2/8/24, R76's nails remained in the same condition. On 2/08/24 at 2:49 PM, Unit Manager J (UM J) was asked to observe R76's fingernails and asked R76's if they preferred their nails that long. R76 stated, No. They said that they can't cut them. UM J stated, the aides or the Nurses are able to cut and clean R76's nails. UM J asked if R76 had to ask to have their nails cleaned or is that routine care. UM J explained that is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practices. Deficient practice statement number one. This citation pertains to Intakes MI00136356 and MI00139987. Based on observation, interview, and record review the facility failed to provide timely tracheotomy care (surgical opening through the neck to help oxygen reach the lungs), obtain a sputum culture, and follow up on recommendations by the Respiratory Therapist, for two residents (R60 and R600) reviewed for tracheotomy care. Findings include: R60 On [DATE] at 9:00 AM, R60 was observed lying in bed with a tracheotomy (trach). R60 was observed to have a loud rattling/gurgling sound that could be heard from the hallway. R60's trach mask was observed to have a large amount of mucus at the bottom of the mask and had visibly soiled the R60's gown. R60's upper body was observed using their accessory muscle with an increase in the rattling/gurgling sound. On [DATE] at 9:04 AM, Unit Manager J was observed at the nurses' station that was located outside of R60's room and was asked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to include a 14-day stop date on a PRN (as needed) anti-anxiety medication for two (R6, R74) of six residents reviewed. Findings include: R74 Review of the facility record for R74 revealed an admission date of 05/27/21 with diagnoses that included Generalized Anxiety Disorder. Further review of R74's record revealed an order for Lorazepam dated 01/22/24 with the instructions Give 0.25 ml orally every four hours as needed for anxiety/agitation. Keep until resident expires. On 02/08/24 this order remained in Active status. On 02/08/24 at 2:36 PM, the facility Director of Nursing (DON) reported that the expectation for a PRN psychotropic medication is that it have a 14-day stop date and that any extension of the order include a physician reassessment and justification. The DON was asked if it was acceptable for a resident receiving hospice services to have a PRN psychotropic medication order with a duration of until resident expires and the DON stated No.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

This citation pertains to Intake MI00140161. Based on interview and record review, the facility failed to provide routine dental care to one resident (R68) out of one reviewed for dental care. Findings Include: On 2/7/2024 at 12:44 PM, an interview was conducted with Family Member (FM) B. FM B stated that they were concerned about R68's dental care. FM B stated that they don't know the last time R68 had seen a dentist, and they believe that R68 is supposed to have some teeth pulled. FM B stated that they have reached out to facility staff, but they do not get back with them. A review of the medical records revealed that R68 re-admitted into the facility on 7/5/2023 with the following medical diagnoses, Major Depressive Disorder and Dementia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 8/15 indicating an impaired cognition. R68 also required one person assist with bed mobility and transfers. A review of the most recent dental exam revealed that R68 last visit was 12/28/2022. The dental notes revealed the following, Recommend…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure quarterly care conferences were completed and/or documented for one resident (R78) out of three reviewed for care conference completion, resulting in the resident not feeling informed and included in their plan of care. Findings Include: On 11/1/2022 at 9:35 AM, an interview was conducted with R78 regarding their stay in the facility. R78 stated that they had been in the facility for over a year and wanted to talk to someone about their options regarding discharging. R78 stated that they have asked for the Social Worker but had not seen them for months. R78 was queried as to if they had care conferences during their stay in the facility. R78 stated that they haven't had a care conference since admission into the facility. A review of the medical record revealed that R78 admitted into the facility on 8/16/2021 with the following diagnoses, Cardiogenic Shock, Anxiety Disorder, and Chronic Obstructive Pulmonary Disease. A review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation has two deficient practice statements. Deficient Practice Statement #1 Based on observation, interview, and record review, the facility failed to ensure call light accessibility for one sampled Resident (R430) of one resident reviewed for accommodation of needs, resulting in unmet care needs and loss of autonomy. Findings include: On 11/1/22 at 10:29 AM, R430 was observed in bed lying on their left side, call light observed on the floor, and out of reach to the resident on floor. R430 asked the surveyor if they could provide them with a sip of water as they were having a difficult time lifting their arms due to pain. R430 was advised to use their call light button, and stated, I can't reach it. A review of R430's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included, a mental status change, and contractures to their upper right and left extremities. Further review of the medical record revealed that the resident required supervision to limited…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to ensure resident electronic health information was kept secure on the Unit 1, for one sampled Resident (R159), resulting in the private resident health information to unknown sources without resident knowledge and permission. Findings include: On 11/03/22 at 12:15 PM, a computer screen on an unattended medication cart, located in the Unit 1 hallway between rooms [ROOM NUMBERS], was noted to be open to R159's medication administration record and picture. On 11/03/22 at 4:14 PM, the Director of Nursing (DON) was asked the facility's expectation for protecting resident's health information. The DON explained, when they (Nurse) walk away they are supposed to close the computer to protect Residents information. A review of the facility's policy titled Resident Rights dated, 11.28.2017, did not address the above concern.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop a comprehensive care plan to address Activities of Daily Living (ADLs) for one sampled resident (R329), resulting unmet care needs. Findings include: On 11/01/22 at 10:00 AM, R329 was observed lying in bed. R329 was unable to be understood due to a communication deficit. On 11/01/22 at 1:47 PM, during an interview with R329's interested party reported, that the resident is not getting any showers because they don't have the right equipment to shower R329 and they are not washing R329's hair. A review of R329's medical record revealed, R329 was admitted on [DATE] with diagnosis of Cerebral Infarction. A review of R329's admission Minimum Data set (MDS) noted, intact cognition, bed mobility, and hygiene as extensive assistance of one person. A review of R329's care plan noted, Focus: The resident has potential for an ADL self-care performance deficit Date Initiated: 09/21/2022. Goal: The resident will demonstrate the appropriate use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure care planned interventions were implemented and person centered for three residents (R107, R29, R2) of seven reviewed, resulting in and or the potential for unmet care needs, resident dissatisfaction and decline. Findings include: On 11/01/22 at 11:34 AM, R107 was observed to be in bed dressed in a hospital style gown. Assist bars were attached the upper/raise portion of the bed. The head of the bed was up around 30-45 degrees. R107's hair appeared slightly matted and tangled from sleeping. R107 was interviewed about the care provided at the facility. R107 reported some concerns about the food, feeling like they were sitting on the bed frame, and that someone had taken their wheelchair out of the room and not returned it. R107's roommate indicated this had happened on different occasions. Observation of the room revealed sufficient storage area for a wheelchair and a walker between the closet cabinets. R107 was also asked about…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow up on therapy recommendations for splint applications for two residents (R79 and R136) out of two reviewed for range of motion, resulting in the potential for decreased ability in affected hand. Findings Include: Resident 79 On 11/01/2022 at 9:35 AM, R79 was observed in their bed. R79 was noted to have a contracture in their left hand. A blue splint was noted sitting on the nightstand. On 11/01/2022 at 10:24 AM, R79 was observed dressed and up in a geri-chair, their splint was noted to be resting on the nightstand. On 11/01/2022 at 4:02 PM, R79's splint was still observed to be resting on the nightstand. A review of the physician orders and task did not reveal a schedule related to the splint. Further review of R79's care plans noted the following, Focus: Splint/Brace: [R79] requires use of splint for contracture management. Date Initiated:04/01/2021. Goal: Resident will wear splint on their L Hand and (Elbow) every day for 8 hours or to tolerance to prevent (Progression) contractures/increases PROM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes: MI00131244 and MI00130510. Based on observation, interview, and record review the facility failed to provide consistent Activities of Daily Living (ADLs), for one sampled resident (R329), resulting in a lack of consistent hygiene needs being met. Findings included: On 11/01/22 at 1:47 PM, during an interview with R329's interested party reported, that the resident is not getting any showers because they don't have the right equipment to shower R329 and they are not washing R329's hair. A review of R329's medical record revealed, R329 was admitted on [DATE] with diagnosis of Cerebral Infarction. A review of R329's admission Minimum Data set (MDS) noted, intact cognition, bed mobility, and hygiene as extensive assistance of one person. A review of R329's care plan noted, Focus: The resident has potential for an ADL self-care performance deficit Date Initiated: 09/21/2022. Goal: The resident will demonstrate the appropriate use of adaptive devices to increase ability through the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 11/01/22 at 10:40 AM, R334 was asked about the care at the facility and stated, I am not getting the supplies that I need for my wounds. I am not sure if they are supposed to come from here (the facility) or from Hospice. A review of R334's medical record revealed, R334 was admitted to the facility on [DATE] with a diagnosis of Osteomyelitis. A review of R334's evaluation titled, BIMS (Brief Interview for Mental Status) Resident Response dated 10/31/22 noted, Cognitively Intact. On 11/03/22 at 1:37 PM, the Unit Secretary was asked for R334's hospice book and stated, [R334] had one but it disappeared. The (hospice) Aide was here yesterday and asked if R334 still did not have a book. A review of R334's care plan noted, Focus: The resident has a terminal/end stage prognosis Date Initiated: 11/01/2022. Goal: The resident's comfort will be maintained through the review date. Date Initiated: 11/01/2022. Intervention: Hospice and facility will coordinate plans of care to manage symptoms such as nausea, agitation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure communication documentation was available between the facility and the dialysis service provider for one resident (R32) of one resident reviewed for dialysis services, resulting in the potential for a lack of coordination/continuity of care. Findings include: On 11/3/22 at 11:05 AM, a physician order dated 9/12/22 was reviewed in R32's electronic medical record (EMR) which stated the following, Dialysis vis [Dialysis provider] Mon-Wed-Fri @6am. Nurse to ensure that resident is up and transport to Dialysis unit. On 11/3/22 at 11:10 AM, a review of R32's dialysis communication documentation in their EMR revealed that R32's most recent dialysis communication was dated 1/28/22. On 11/3/22 at 1:52 PM, an unidentified facility staff member provided the surveyor with paper dialysis communication documents pertaining to R32 and stated, They just faxed it over today. On 11/3/22 at 3:03 PM, the Director of Nursing (DON) was interviewed regarding their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide honey thick liquids per Speech and Language Pathology (SLP) recommendations for one sampled resident (R2) of one reviewed for liquid consistency, resulting in the potential for choking and aspiration (accidental breathing of food or fluid into the lungs, which can cause pneumonia). Findings include: On 11/1/22 at 1:27 PM, R2 was observed sitting up in bed eating lunch. They were unable to be interviewed due to their cognition however, their meal ticket was observed on their meal tray indicating they required feeding assistance, and could not have straws however, the resident water cup was observed to have a straw inside the cup. A review of R2's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Dysphagia, Heart Failure and Dementia. Further review of the resident medical record revealed that they were severely cognitively impaired, and required extensive assistance for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain facility COVID-19 infection surveillance or utilize a system for tracking COVID-19 infections for staff and residents, ensure proper Personal Protective Equipment (PPE) for source control was worn in resident care areas, initiate transmission-based precautions for a resident exposed to COVID-19, resulting in the potential undetected spread of infectious agents and communicable diseases like COVID-19 affecting all 177 residents in the facility. Findings include: On 11/2/22 at 2:21 PM, Infection Control Preventionist (ICP) and ICP B were asked to provide a list of their COVID positive residents and staff, in addition to the staff vaccination matrix which had not been provided to surveyors on the first day of survey. The requested documents were not readily available to review; therefore, a review of the Infection Control program was rescheduled for the following day. It was also confirmed that the facility was currently having a COVID-19 outbreak. On 11/2/22 at 3:41 PM, Infection Control documents were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to operationalize policies and procedures to ensure Influenza and Pneumococcal vaccinations were offered with accessible documentation of acceptance or declination in the medical record for one sampled resident (R4) out of five residents reviewed for immunizations, resulting in the potential to expose each resident to the highly infectious Influenza. Findings include: A review of R4's medical record revealed that they had not received the Influenza immunization. In addition, there were no declinations for influenza or pneumonia vaccinations for 2021 or 2022 noted in the resident's medical record or the infection control binder provided by the Infection Control Preventionist (ICP). On 11/3/22 at 3:06 PM, the most recent Pneumonia and Influenza declination forms were requested from the facility which provided the following progress note: 11/3/2022 15:45 (3:45pm) Spoke with [Guardian] this day. Writer spoke with [them] earlier (end of September). [They do] not want R4 to take the flu shot saying the doctor at [local hospital]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure furnishings were maintained in six rooms (320, 321, 326, 328, 332, 409) resulting in loose or missing doors, handles and drawer fronts. Findings include: On 11/01/22 at 10:42 AM, during the initial tour or resident rooms the following was observed: In room [ROOM NUMBER] the faced of the middle drawer of the three door night stand was missing. The dowels for the face were visible as were the resident items in the box of the drawer; In room [ROOM NUMBER] the door was off the left side of the standing closet unit; In room [ROOM NUMBER] the door to the left side of the standing closet unit was loose and was angled-the resident indicated it was not newly broken; In room [ROOM NUMBER] bed B the night stand handle on the middle drawer of the three door night stand hung down on one side; In room [ROOM NUMBER] the standing fan had a layer of gray dust buildup on the tines of the protective cover; In room [ROOM NUMBER] the right side closet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.